Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

SUTTER SANTA ROSA REGIONAL HOSPITAL

CA · Facility ID 050291 · FY2026

Total HAC Score

-0.5193

Percentile

19.3th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.5193

Hospital score -0.5193. Penalty threshold 0.3792. Distribution of 2929 scored hospitals.

Data completeness

Reported on 6 of 6. Missing measures show N/A with the CMS footnote; footnote 18 values are imputed worst-case, not measured performance.

  • PSI-90z 0.296
  • CLABSIz -0.866
  • CAUTIz -1.044
  • SSIz -1.177
  • CDIz -0.576
  • MRSAz 0.250

Fragility

Each reported measure moves the score by 0.1667 points.

Score swing if each reported measure were at its Z floor versus Z cap, holding other measures fixed
MeasureCurrent ZScore @ floorScore @ capAbs swing
PSI-90controls fate0.2963-0.8160-0.15020.6657
CAUTI-1.0438-0.56510.05230.6175
MRSA0.2502-0.8039-0.19020.6137
CDI-0.5755-0.6671-0.05790.6092
CLABSI-0.8660-0.6094-0.00160.6078
SSI-1.1773-0.56590.03880.6047

Swing is a mechanics illustration: replace one reported Z with that measure’s observed floor or cap while holding others fixed. Ranked by absolute swing.

Peer context

Percentile within CA (277 scored): 17.1th

Score distributionThreshold 0.3792Hospital -0.5193

Hospital score -0.5193. Penalty threshold 0.3792. Distribution of 277 scored hospitals.

Percentile among hospitals with 6 reported measures (1940 scored): 13.5th

Score distributionThreshold 0.3792Hospital -0.5193

Hospital score -0.5193. Penalty threshold 0.3792. Distribution of 1940 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.5193; threshold 0.3792).

Reported on 6 of 6 measures; each reported measure moves the equal-weighted score by 0.1667 points.

Describes scoring mechanics only. Not medical or legal advice. Any “would / would not” language is an illustration against the published threshold, not a CMS prediction.

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